Osseous Pathology on Wrist Magnetic Resonance Imaging.

Advanced imaging of the osseous structures of the wrist by magnetic resonance imaging (MRI) yields powerful information regarding marrow composition and overall bone structure. Various forms of pathology, both benign and malignant, have unique marrow signal abnormalities that can be easily detected by MRI given its high sensitivity to radiographically occult processes. In particular, osseous pathology can be seen in the setting of traumatic, degenerative, congenital, infectious, and neoplastic conditions. The acuity or chronicity of these conditions can often be determined by imaging to aid in appropriate therapy. A thorough understanding of the breadth of pathology and corresponding MRI appearances can allow the interpreting radiologist to formulate a concise and accurate assessment of an examination.

Characterizing hand and wrist ultrasound pattern in primary Sjögren's syndrome: a case-control study.

INTRODUCTION/OBJECTIVES: To evaluate the clinical relevance of high-resolution hand and wrist ultrasound (US) findings and their possible associations with anti-citrullinated peptide antibodies in primary Sjögren's syndrome (pSS). METHODS: Ninety-seven consecutive pSS patients (American-European Consensus Group, 2002) without meeting the American College of Rheumatology (ACR) criteria (1987) for rheumatoid arthritis (RA); 20 RA patients (ACR/European League Against Rheumatism (EULAR) criteria, 2010); and 80 healthy individuals with comparable age, gender, and ethnicity were enrolled in a case-control study. Disease activity was assessed by EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI). US was performed by one expert blinded to anti-CCP, anti-MCV, and IgM rheumatoid factor tested by ELISA. RESULTS: Frequencies of grade 3 synovitis (9.3 vs. 0%, p = 0.004), tenosynovitis (36.1 vs. 3.8%, p < 0.001), and erosions (27.8 vs. 7.5%, p = 0.001) on US were higher in pSS patients than in healthy controls. ESSDAI presented a moderate correlation with the synovitis number (p = 0.001) and tenosynovitis (p < 0.001). Most pSS patients with erosions on US (81.5%) had negative anti-CCP. Nevertheless, anti-CCP ≥ 3× cut-off value was associated with the presence of erosions in pSS (p = 0.026). Erosions in pSS were mainly small size contrasting with moderate/large size in RA (p < 0.001), and positive power Doppler synovitis predominated in RA (p < 0.001). CONCLUSIONS: US identified significant frequencies of grade 3 synovitis, tenosynovitis, and erosions in pSS. Synovitis and tenosynovitis numbers were correlated with ESSDAI. Association between erosions on US and anti-CCP (high titers) in pSS possibly identifies a subgroup with severe arthritis. These findings suggest that US is a useful method for assessing joint involvement in pSS.Key Points• US identified significant frequencies of grade 3 synovitis, tenosynovitis, and erosions in pSS patients in comparison with age- and race-healthy individuals.• Numbers of synovitis and tenosynovitis on US were correlated with ESSDAI values.• Most pSS patients with erosions on US were negative for anti-CCP, but anti-CCP ≥ 3× cut-off value was associated with the presence of erosions in this disease.• Erosions in pSS were mainly small size contrasting with moderate/large size in RA, and positive power Doppler synovitis predominated in RA.

Lichen sclerosus et atrophicus: atypical case simulating lichen planus.

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory dermatosis, characterized by shiny, atrophic, hypochromic papules with a predilection for the genital and perineal skin. Extragenital involvement may occur, but is rare in the isolated form. LSA more commonly affects prepubertal and postmenopausal women. We describe an unusual case of isolated extragenital LSA, restricted to the wrists and mimicking lichen planus.

Bone Age and Mineral Density Assessments Using Plain Roentgenograms in Tenofovir-exposed Infants in Malawi and Brazil Enrolled in HIV Prevention Trials Network 057.

BACKGROUND: Tenofovir disoproxil fumarate (TDF) use during pregnancy has been increasing, and studies linking bone toxicity with exposure to TDF have raised concern for its use in infants. METHODS: Hand/wrist and spine radiographs were obtained at 3 days and 12 weeks of age in infants born to HIV-infected pregnant women enrolled in the HIV Prevention Trials Network 057 pharmacokinetic study of TDF conducted in Malawi and Brazil assigned to 3 TDF dosing cohorts. In cohort 1, mothers received 600 mg of TDF during labor. In cohort 2, infants received 4 mg/kg dose on days 0, 3 and 5. In cohort 3, a 900 mg maternal dose was given during labor, followed by a 6 mg/kg infant dose on days 0, 3 and 5 of life. RESULTS: Across all 3 cohorts, 89 infants had radiographs performed at either time point, and 85 had radiographs performed at both time points. Metaphyseal lucency was present in 1 case in Brazil and 2 in Malawi. Fifteen percent of infants from Brazil and 9% of infants from Malawi presented bone age discrepancies. No other abnormalities were identified in Brazil, whereas in Malawi, there were 7 more cases of wrist osteopenia, 2 of spine osteopenia and 3 other abnormalities. CONCLUSION: Bone abnormalities were not uncommon in the overall cohort of HIV-exposed infants. Because of very limited study drug exposure at the time of birth, it is unlikely that TDF was associated with these findings. Untreated maternal HIV disease and/or maternal nutritional status could potentially be related to fetal bone development. This association should be explored in future cohort studies.

Theoretical distribution of load in the radius and ulna carpal joint.

PURPOSE: The purpose of this study is to validate a model for the analysis of the load distribution through the wrist joint, subjected to forces on the axes of the metacarpals from distal to proximal for two different mesh densities. METHOD: To this end, the Rigid Body Spring Model (RBSM) method was used on a three-dimensional model of the wrist joint, simulating the conditions when making a grip handle. The cartilage and ligaments were simulated as springs acting under compression and tension, respectively, while the bones were considered as rigid bodies. At the proximal end of the ulna the movement was completely restricted, and the radius was allowed to move only in the lateral/medial direction. RESULTS: With these models, we found the load distributions on each carpal articular surface of radius. Additionally, the results show that the percentage of the applied load transmitted through the radius was about 86% for one mesh and 88% for the coarser one; for the ulna it was 21% for one mesh and 18% for the coarser. CONCLUSIONS: The obtained results are comparable with previous outcomes reported in prior studies. The latter allows concluding that, in theory, the methodology can be used to describe the changes in load distribution in the wrist.

Corticoid injection as a predictive factor of results of carpal tunnel release

OBJECTIVE: To evaluate whether the symptoms relief after local corticoid injection correlate with better results of surgical treatment in carpal tunnel syndrome. METHODS: Between February 2011 and June 2013, 100 wrists of 88 patients were included in the study. All patients were subjected to corticoid injections in the carpal tunnel and evaluated before and after infiltration and surgery. The following parameters were evaluated: visual analog scale (VAS) for pain, Boston questionnaire, sensitivity and strength. RESULTS: Only 28 out of 100 wrists subjected to injection were symptom-free after six months follow up. Sixty out of the 72 patients who did not present relief or relapse symptoms were treated surgically. Surgical results were better regarding VAS, Boston questionnaire and sensitivity in a specific group of patients, which had a longer relief of symptoms after the corticoid injection, with statistical significance. CONCLUSION: Longer relief of symptoms after corticoid injection correlated with better results of surgical treatment. Level of Evidence II, Prognostic Study.

Joint involvement in primary Sjögren's syndrome: an ultrasound "target area approach to arthritis".

OBJECTIVE: To characterize the ultrasound (US) pattern of joint involvement in primary Sjögren's syndrome (pSS). METHODS: Seventeen patients with pSS, 18 with secondary Sjögren's syndrome (sSS), and 17 healthy controls underwent US examinations of various articular regions. Synovitis (synovial hypertrophy/joint effusion), power Doppler (PD) signals, and erosions were assessed. RESULTS: In patients with pSS, synovitis was found in the metacarpophalangeal joints (MCP, 76%), wrists (76%), and knees (76%), while the proximal interphalangeal joints, elbows, and ankles were mostly unscathed. Intra-articular PD signals were occasionally detected in wrists (12%), elbows (6%), and knees (6%). Erosions were evident in the wrists of three (18%) patients with pSS, one of these also having anti-cyclic citrullinated peptide (anti-CCP) antibodies. While US synovitis does not discriminate between sSS and pSS, demonstration of bone erosions in the 2nd MCP joints showed 28.8% sensitivity and 100% specificity for diagnosing sSS; in comparison, these figures were 72.2 and 94.1% for circulating anti-CCP antibodies. CONCLUSIONS: In pSS, the pattern of joint involvement by US is polyarticular, bilateral, and symmetrical. Synovitis is the US sign most commonly found in patients with pSS, especially in MCP joints, wrists, and knees, and bone erosions also may occur.

Acquired segmental neuromas.

Neuromas are benign hyperplastic proliferations of normal peripheral nerve components. These can be associated with some genodermatoses, namely Cowden syndrome and multiple endocrine neoplasia (MEN) 2B, especially when numerous lesions are present. Given the potential for malignancy (such as breast cancer, pheochromocytoma, and thyroid cancer) associated with these syndromes, other features indicative of either syndrome should be evaluated in patients presenting with multiple cutaneous neuromas. The evaluation should include a thorough family history and complete physical, dermatologic, and ophthalmologic exams as well as thyroid studies. We report, herein, the case of an 8-year-old female with cutaneous neuromas distributed segmentally with no other associated finding suggestive of an underlying syndrome.

Osteomielite de punho em paciente com paracoccidioidomicose disseminada: uma rara apresentação / Osteomyelitis of the wrist in a patient with disseminated paracoccidioidomycosis: a rare presentation

Paracoccidioidomicose é a micose sistêmica endêmica mais frequente no Brasil. No início, o paciente não desenvolve sintomas. Com a progressão da doença, o indivíduo pode apresentar envolvimento disseminado, sendo que o acometimento ósseo é extremamente raro. O objetivo deste artigo é avaliar as alterações ósseas encontradas em estudos de imagem em um paciente com osteomielite de punho decorrente de paracoccidioidomicose disseminada.

Paraccocidioidomycosis is the most frequently found endemic systemic mycosis in Brazil. No symptoms are observed in the early phases of the disease. As the disease progresses, the patient may present disseminated involvement, but bone involvement is extremely rare. The present report is aimed at evaluating bone changes found on imaging studies in a patient with osteomyelitis of the wrist as a result of disseminated paracoccidioidomycosis.

Indicações de artroplastia radiocubital distal: relato de três casos clínicos / Indications for distal radio-ulnar arthroplasty: report on three clinical cases

A artroplastia radiocubital distal é uma solução atrativa no tratamento de diferentes patologias da articulação radiocubital distal, pois permite restaurar a estabilidade, a transmissão de cargas e a função. As principais indicações são: o impingement radiocubital após ressecção parcial ou completa do cúbito distal e a artrite degenerativa, inflamatória ou pós-traumática da articulação radiocubital distal. Os autores apresentam três casos clínicos de patologia radiocubital distal: dois pacientes com sequelas pós-traumáticas e um caso de impingement radiocubital distal após operação de Sauvé-Kapandji. Os três casos foram tratados cirurgicamente com prótese metálica de substituição do cúbito distal tipo First Choice - Ascencion®. Os dois primeiros foram tratados com prótese tipo resurfacing e o último com prótese tipo modular. Em todos os pacientes obteve-se diminuição da dor e aumento da amplitude da RCD ao fim de um ano de seguimento pós-cirúrgico.

Distal radioulnar arthroplasty is an attractive solution for treating various pathological conditions of the distal radioulnar joint because it allows restoration of stability, load transmission and function. The main indications are: radioulnar impingement after partial or complete resection of the distal ulna; and degenerative, inflammatory or post-traumatic arthritis of the distal radioulnar joint. The authors present three clinical cases of distal radioulnar pathological conditions: two patients with post-traumatic sequelae and one case of distal radioulnar impingement after a Sauvé-Kapandji operation. The three cases were treated surgically with a metallic prosthesis to replace the distal ulna (First Choice - Ascension®). The first two were treated with a resurfacing prosthesis and the last one with a modular prosthesis. All of the patients had achieved pain relief and increased movement of the distal radioulnar joint after one year of postoperative follow-up.

La ultrasonografía en el estudio de la patología regional de la mano y la muñeca: [revisión] / Ultrasound in the evaluation of hand and wrist disorders: [review]

La mano y la muñeca son frecuentemente implicadas en síndromes de dolor regional, inflamatorios y degenerativos. La ultrasonografía ha demostrado ser más sensible que los exámenes clínicos y de radiología convencional para la detección de sinovitis y erosiones. También ha podido revelar una participación subclínica en pacientes con artritis crónica. Las indicaciones de la ultrasonografía a nivel de la mano y la muñeca son amplias e incluyen el diagnóstico de la afección articular y el tendón, la patología de poleas, los cambios morfoestructurales a nivel del nervio mediano en el túnel carpiano; puede servir como guía para las infiltraciones, así como para la valoración del tratamiento en pacientes con artritis crónica. El objetivo de esta revisión es mostrar el resultado de las alteraciones más frecuentes en las que la ultrasonografía ha demostrado ser útil.

The hand and wrist are frequently involved by regional pain syndromes, inflammatory and degenerative conditions. Ultrasonography had demonstrated to be more sensitive than both clinical examination and conventional radiology for the detection of synovitis and erosions. It has also able to reveal a subclinical involvement in patients with chronic arthritis. The indications of ultrasonography at hand and wrist level is wide and include: diagnosis of joint and tendon involvement, pulleys pathology, morphostructural changes at median nerve level into to carpal tunnel, guidance for infiltrations into and treatment monitoring in patients with chronic arthritis. The aim of this review is to show the most frequent alterations in which ultrasound has proven useful.

Tuberculosis de la muñeca y de la mano / Tuberculosis of the hand and wrist

Introducción: La tuberculosis osteoarticular se observa en la columna, la rodilla y la cadera y, menos a menudo,en las vainas tenosinoviales, y en los huesos de la mano y la muñeca. El objetivo del presente trabajo es analizar esta patología y su tratamiento, y valorar la técnica de reconstrucción simultánea a largo plazo. Materiales y métodos: El estudio abarca a 19 pacientes tratados en 45 años, correspondientes a: 3 espinas ventosas, 10 tenosinovitis de flexores, 4 tenosinovitis de extensores y 2 artritis de muñeca. Empleamos una metodología diagnóstica moderna y el estudio retrospectivo de los pacientes, sus tratamientos y resultados. Resultados: El tratamiento farmacológico correcto es eficaz en 99 por ciento de los casos para la infección tuberculosa. El quirúrgico acelera la curación y consiste en la resección de los tejidos necróticos y la reconstrucción funcional, primaria o secundaria. La curación de la infección se logra siempre; la recuperación funcional estará en relación con el tipo, la. gravedad y la extensión de la lesión. Conclusiones: Se demuestra la frecuencia de estas patologías en los trabajadores de la carne o que están en contacto diario con hacienda. Se destacan los procedimientos modernos de diagnóstico. Se enfatiza en un tratamiento médico completo en calidad, duración y tipo de fármacos. Se destacan las bondades de los tratamientos quirúrgicos y de la reconstrucción funcional simultánea que propusimos en 1965.(AU)

Tuberculosis de la muñeca y de la mano / Tuberculosis of the hand and wrist

Introducción: La tuberculosis osteoarticular se observa en la columna, la rodilla y la cadera y, menos a menudo,en las vainas tenosinoviales, y en los huesos de la mano y la muñeca. El objetivo del presente trabajo es analizar esta patología y su tratamiento, y valorar la técnica de reconstrucción simultánea a largo plazo. Materiales y métodos: El estudio abarca a 19 pacientes tratados en 45 años, correspondientes a: 3 espinas ventosas, 10 tenosinovitis de flexores, 4 tenosinovitis de extensores y 2 artritis de muñeca. Empleamos una metodología diagnóstica moderna y el estudio retrospectivo de los pacientes, sus tratamientos y resultados. Resultados: El tratamiento farmacológico correcto es eficaz en 99 por ciento de los casos para la infección tuberculosa. El quirúrgico acelera la curación y consiste en la resección de los tejidos necróticos y la reconstrucción funcional, primaria o secundaria. La curación de la infección se logra siempre; la recuperación funcional estará en relación con el tipo, la. gravedad y la extensión de la lesión. Conclusiones: Se demuestra la frecuencia de estas patologías en los trabajadores de la carne o que están en contacto diario con hacienda. Se destacan los procedimientos modernos de diagnóstico. Se enfatiza en un tratamiento médico completo en calidad, duración y tipo de fármacos. Se destacan las bondades de los tratamientos quirúrgicos y de la reconstrucción funcional simultánea que propusimos en 1965.

Resección artroscópica de gangliones dorsales: técnica quirúrgica / Arthroscopic resection of dorsal ganglia: surgical technique

El ganglión dorsal es la tumoración benigna más frecuente de la muñeca y su origen es habitualmente constante a nivel de la confluencia de la cápsula dorsal con el ligamento escafolunar. El diagnóstico se realiza con ecografía o resonancia magnética siendo las radiografías estándares normales. La técnica quirúrgica artroscópica se realiza con tracción de la muñeca introduciendo el artroscopio por el portal 6R y el shaver por el 3-4, realizando sinovectomía y capsulectomía de 1 cm² de la zona de implante del pedículo del ganglión, en la cápsula dorsal, hasta la visualización del 2º radial externo. La complicación más frecuente es la recidiva. Desde el punto de vista estético el resultado es más satisfactorio que la cirugía a cielo abierto.

Resección artroscópica de gangliones dorsales: técnica quirúrgica / Arthroscopic resection of dorsal ganglia: surgical technique

El ganglión dorsal es la tumoración benigna más frecuente de la muñeca y su origen es habitualmente constante a nivel de la confluencia de la cápsula dorsal con el ligamento escafolunar. El diagnóstico se realiza con ecografía o resonancia magnética siendo las radiografías estándares normales. La técnica quirúrgica artroscópica se realiza con tracción de la muñeca introduciendo el artroscopio por el portal 6R y el shaver por el 3-4, realizando sinovectomía y capsulectomía de 1 cm² de la zona de implante del pedículo del ganglión, en la cápsula dorsal, hasta la visualización del 2º radial externo. La complicación más frecuente es la recidiva. Desde el punto de vista estético el resultado es más satisfactorio que la cirugía a cielo abierto.(AU)

Coexistence of prostate cancer, gynecomastia, renal failure, melanonychia, and wrist lump.

Although prostate cancer is among the most frequent malignancies in the elderly, this tumor may be under-reported, and it seems that its socioeconomic burden is not well-estimated. Chronic urinary obstruction caused by the cancer may cause renal failure, with hemorrhagic tendency, neurologic disturbances, cutaneous disorders, and diverse fingernail changes. Black or brown nail pigmentation has been associated with benign and malignant conditions, including antineoplastic drugs' side effects, subungual metastases, and melanoma. Metastasis of fingernail melanoma can affect lymph nodes from the wrist to elbow and axillary regions. Coexistent melanonychia and wrist lump, mimicking melanoma with sentinel lymph node is reported. It is recommended to consider the differential diagnosis of nail changes due to chronic renal failure.

Os efeitos da mobilização neural como abordagem fisioterapêutica na síndrome do túnel do carpo / The effects of neural mobilization as physical therapy approach in carpal tunnel syndrome

A síndrome do túnel do carpo é uma neuropatia compressiva periférica que consiste na compressão do nervo mediano no canal do carpo. Apresenta maior incidência no sexo feminino e está associada ao esforço repetitivo. Os sinais e sintomas mais freqüentes são fraqueza, hipotrofia dos músculos tenares e dos dois primeiros lumbricais, retração do adutor do polegar e dos músculos flexores profundos e superficiais dos dedos, perda da mobilidade no deslizamento longitudinal e transversal do nervo mediano. Esses estão associados a edema, inflamação e retração do tecido conjuntivo neural. O objetivo deste estudo foi mostrar a aplicação da técnica de mobilização neural, como tratamento para a síndrome do túnel do carpo. Tal técnica tem como principal objetivo restaurar o movimento e a elasticidade tecidual do nervo periférico.

The carpal tunnel syndrome is a peripheral compressive neuropathy that consists in median nerve compression in the carpal tunnel. It occurs more often in females and is associated with repetitive strain. The more frequent signals and symptoms are weakness, hypertrophy of the tenhar and the first two lumbrical muscles, retraction of adductor of thumb and the deep and superficial flexor finger muscles, loss of mobility in the longitudinal and transverse sliding of the median nerve. These signals and symptoms are associated with swell, inflammation and retraction of the conjunctive neural tissue. The objective of the study aimed to show the use of neural mobilization technique as treatment for the carpal tunnel syndrome. Such technique has as main objective to restore range of motion and elasticity of the peripheral nerve tissue.

Patologia tendinea, vascular y tumoral de la mano: hallazgos ultrasonograficos / Tendons, vascular and tumoral pathology of the hand: sonographical findings

El desarrollo de transductores de alta resolución (10-15 MHz), permite ahora evaluar con certeza, en forma rápida y a bajo costo, lesiones inflamatorias, traumáticas y tumorales de las manos. Esta presentación analiza los hallazgos ultrasonográficos de las patologías más frecuentes de la mano. Esto incluye tenosinovitis, roturas tendíneas, lesiones vasculares y tumorales.

Quiste oseo yuxtaarticular: estudio clinicopatologico / Juxta-articular bone cyst: clinical and pathologic study

El quiste oseo yuxtaarticular es una lesion quistica benigna localizada en el hueso subcondral adyacentea una articulacion, no relacionada con enfermedades articulares inflamatorias o degenerativas. Entre los años 1986 y 2000 se realizo un estudio retrospectivo de 116 pacientes con el diagnostico de dicha patologia obtenido por puncion o biopsia. Se utilizaron 2 parametros para ser evaluados: el clinicorradiologico y la investigacion anatomopatologica. Se detecto un predominio en el sexo femenino y en la cuarta decada de la vida. Las localizaciones mas frecuentes fueron las articulaciones de la cadera, la rodilla, el tobillo y la muñeca. En la mayoria de los casos los quistes fueron detectados por hallazgo. El dolor fue el sintoma predominante. La medicion quistica arrojo valores entre 1 y 2 cm.; algunos alcanzaron 4 cm. La anatomia patologica evidencio su naturaleza multiocular observandose una pared fibrosa de espesor variable con areas de degeneracion mixoide y formacion de quistes mas pequeños rodeada por escaso tejido oseo maduro escleroso. El tratamiento fue el curetaje; en los casos en que el tamaño era importante se utilizo el agregado de injerto oseo. El objetivo del presente trabajo es actualizar el tema mediante el analisis casuistico

Técnica punho tornozelo / Technical ankle cuff

Método de tratamento pelo punho-tornozelo. Localização e técnica de inserção de agulhas. Técnica Punho-tornozelo - posições dos pontos do punho. Técnica Punho-tornozelo - posições dos pontos do tornozelo. Indicação do método Punho-tornozelo. Aplicação clínica do método punho-tornozelo. Estudo de casos